Evaluation of Clinical and Venous Blood Parameters as Surrogate Indicators in Assessing the Need for Fasciotomy in Lower Limb Compartment Syndrome

Acute compartment syndrome in the lower limb, a surgical emergency, may cause ischemic damage to muscles and neurological deficits leading to loss of function of the limb which may even require amputation, thus drastically affecting the quality of life of a patient. Fasciotomy for decompression is suggested when the differential pressure in the compartment of the leg is ≤30 mm Hg. However, compartment pressure measurement is not always feasible. Surgeons often find themselves in a dilemma in deciding the right treatment option for the patient: fasciotomy or conservative management. Since there is no universally accepted reference standard for the diagnosis of acute compartment syndrome at present, there is a need for definitive diagnostic variables so as to not delay fasciotomy in patients who need it, as well as to avoid unnecessary fasciotomies, especially when compartment pressures cannot be measured. In this observational study including 71 patients, based on the compartment pressures of the affected limb, treatment was done either with fasciotomy or conservative approach, and various clinical and biochemical parameters were evaluated in between these two groups. Statistically significant difference was found in the venous blood gas parameters between patients managed conservatively and with fasciotomy (MANOVA, P = .001). The results revealed the association of lower venous blood bicarbonate levels (independent sample t test, P = .021) and the presence of paresthesia (Fisher exact test, P = .0016) with the fasciotomy group. Also, pain on passive stretching of the affected limb was found to be significantly associated with a delta pressure of ≤30 mm Hg in any compartment (Fisher exact test, P = .002). These variables may thus be used as an alternative to the measurement of compartment pressure to assess the requirement of fasciotomy.

Forearm compartment pressures and grip strength in elite motorbike racers with chronic exertional compartment syndrome

Background Remarkably little research has been published on chronic exertional compartment syndrome (CECS) of the forearm. This study investigated forearm flexor compartment pressure pre- and post-exercise in elite motorbike racers clinically diagnosed with CECS and assessed their grip strength before and after arm pump exercise. Methods Elite motorbike riders with a clinical diagnosis of CECS of the right forearm when racing were recruited during the opening rounds of a British Superbike season. Their grip strength and forearm flexor compartment pressures were measured before and after a set exercise programme. Results Of the 11 riders recruited to the study, 10 completed the full testing regime. The mean pre-exercise forearm compartment pressures [11.7 mmHg (range 7–17 mmHg)] significantly increased post-exercise [30.5 mmHg (range 15–45 mmHg)], with a mean increase of 18.80 mmHg (P < 0.0001). The mean pre-exercise grip strength [50.61 mmHg (range 37–66.7 mmHg)] decreased post-exercise to [35.62 mmHg (range 17.1–52.5 mmHg)], a mean decrease of 14.99 mmHg (P < 0.0001). Conclusion There is a statistically significant increase in the forearm flexor compartment pressures in elite motorbike racers with CECS, but with marked variability of these values. Grip strength decreases statistically significantly following onset of symptoms of CECS of the forearm.

Functional alignment achieves soft tissue balance in total knee arthroplasty as measured with quantitative sensor-guided technology

Aims Total knee arthroplasty (TKA) using functional alignment aims to implant the components with minimal compromise of the soft-tissue envelope by restoring the plane and obliquity of the non-arthritic joint. The objective of this study was to determine the effect of TKA with functional alignment on mediolateral soft tissue balance as assessed using intraoperative sensor-guided technology. Methods This prospective study included 30 consecutive patients undergoing robotic-assisted TKA using the Stryker PS Triathlon implant with functional alignment. Intraoperative soft tissue balance was assessed using sensor-guided technology after definitive component implantation; soft tissue balance was defined as intercompartmental pressure difference (ICPD) of < 15 psi. Medial and lateral compartment pressures were recorded at 10°, 45°, and 90° of knee flexion. This study included 18 females (60%) and 12 males (40%) with a mean age of 65.2 years (SD 9.3). Mean preoperative hip-knee-ankle deformity was 6.3° varus (SD 2.7°). Results TKA with functional alignment achieved balanced medial and lateral compartment pressures at 10° (25.0 psi (SD 6.1) vs 23.1 psi (SD 6.7), respectively; p = 0.140), 45° (21.4 psi (SD 5.9) vs 20.6 psi (SD 5.9), respectively; p = 0.510), and 90° (21.2 psi (SD 7.1) vs 21.6 psi (SD 9.0), respectively; p = 0.800) of knee flexion. Mean ICPD was 6.1 psi (SD 4.5; 0 to 14) at 10°, 5.4 psi (SD 3.9; 0 to 12) at 45°, and 4.9 psi (SD 4.45; 0 to 15) at 90° of knee flexion. Mean postoperative limb alignment was 2.2° varus (SD 1.0°). Conclusion TKA using the functional alignment achieves balanced mediolateral soft tissue tension through the arc of knee flexion as assessed using intraoperative pressure-sensor technology. Further clinical trials are required to determine if TKA with functional alignment translates to improvements in patient satisfaction and outcomes compared to conventional alignment techniques.

Acute Compartment Syndrome After Isolated Soleus Tear in an Elderly Recreational Athlete

Case: A 62-year-old man without significant medical history (no anticoagulation) presented to the emergency department with intense leg pain following a short track race, during which he felt a pop in his calf. His physical exam was highly concerning for acute compartment syndrome (ACS) despite the lack of a typical mechanism or fracture. Compartment pressures were measured and found to be significantly elevated. He underwent compartment releases revealing a medial soleus tear with 400–500 cc hematoma. Conclusion: The case presents a patient with ACS after a soleus muscle tear. Prompt recognition and fasciotomy led to a good clinical outcome. Physicians should recognize that not only gastrocnemius tears can lead to compartment syndrome.

Lateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical study

ObjectivesGiven the common occurrence of residual laxity and re-injury post anterior cruciate ligament reconstruction (ACLR), additional anterolateral procedures are increasingly used in combination with an ACLR. Despite the perception that there is a risk of over-constraining the lateral tibiofemoral (LTF) compartment, potentially leading to osteoarthritis, assessment on their effect on intra-articular compartment pressures is still lacking. Our objective was therefore, through a pilot biomechanical study, to compare LTF contact pressures after the most commonly used anterolateral procedures.MethodsA controlled laboratory pilot study was performed using 4 fresh-frozen cadaveric whole lower limbs. Through 0° to 90° of flexion, LTF contact pressures were measured with a Tekscan sensor, located under the lateral meniscus. Knee kinematics were obtained in 3 conditions of rotation (NR: neutral, ER: external and IR: internal rotation) to record the position of the knees for each loading condition. A Motion Analysis system with a coordinate system based on CT scans 3D bone modelling was used. After an ACLR, defined as the reference baseline, 5 anterolateral procedures were compared: anterolateral ligament reconstruction (ALLR), modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh procedures. The last 3 procedures were randomised. For each procedure, the graft was fixed in NR at 30° of flexion and with a tension of 20 N.ResultsCompared with isolated ACLR, addition of either ALLR or modified Ellison procedure did not increased the overall LTF contact pressure (all p>0.05) through the full range of flexion for the IR condition. Conversely, deep Lemaire, superficial Lemaire and modified MacIntosh procedure (all p<0.05) did increase the overall LTF contact pressure compared with ACLR in IR. No significant difference was observed in ER and NR conditions.ConclusionThis pilot study, comparing the main anterolateral procedures, revealed that addition of either ALLR or modified Ellison procedure did not change the overall contact pressure in the LTF compartment through 0° to 90° of knee flexion. In contrast, the deep and superficial Lemaire, and modified MacIntosh procedures significantly increased overall LTF contact pressures when the knee was internally rotated.

A Retrospective Chart Review to Examine Intra-Compartment Pressures and Post-Operative Outcomes of Chronic Exertional Compartment Syndrome

Category: Other Introduction/Purpose: Chronic exertional compartment syndrome (CECS) is defined as reversible, insufficient blood supply to a fascial compartment’s contents. Patients with this condition have abnormally elevated pressures within specific fascial compartments, causing decreased blood flow to that area. This temporary loss of blood supply produces a feeling of tightness in the affected muscles, pain, and possibly local paresthesia. Surgical treatment involves a fasciotomy, which releases the implicated compartment’s fascia. This procedure creates additional space for muscle expansion and more adequate blood supply to the appropriate tissues.The purpose of this study is to review the surgical outcomes of patients diagnosed with lower extremity CECS whom received a fasciotomy, assessing correlations between resting intramuscular compartment pressures and surgical outcomes. Methods: A retrospective chart analysis was performed of the senior author’s patients between January 1st, 2013 and June 30th, 2019. Patients included in this study presented with symptoms consistent with lower extremity CECS and had the diagnosis confirmed, either unilaterally or bilaterally, via the resting intramuscular pressure cutoff (>=15 mmHg) outlined by the Pedowitz criteria. These patients subsequently received fasciotomies for the syndrome. Results: Out of the 37 patients included in this study, 30 (81.1%) reported improvement in their post-operative pain scores. There was a trend (P > 0.1523) between resting intra-compartment pressures and post-operative pain improvement. Conclusion: Our study suggests a positive trend between higher resting intra-compartment pressures and post-operative pain improvement. Due to the limited number of study participants, no correlations could be determined. However, this data is significant because it demonstrates the importance of the Pedowitz diagnostic criteria, as it is the first study showing a relationship between the resting pressure criteria and surgical outcomes. Further research is necessary to determine if there is a correlation between higher intramuscular pressures and positive surgical outcomes.

Structural anatomy of deep fascia, it’s implication in the pathogenesis of compartment syndrome of upper limbs and objective assessment of the effect of fasciotomy

Background: Deep fascia is dense and well developed in limbs. In the upper limb the deep fascia is tightly adherent to the underlying muscles especially in the forearm, thereby, restricting the space available to muscular swelling causing painful compartment syndrome. Division of this inelastic fascia or fasciotomy is an emergency procedure to decrease the morbidity and mortality.Methods: 30 patients with acute compartment syndrome of the upper extremity of various aetiologies were studied. Adults with painful, swollen and tense upper extremities with progressive neurological dysfunction were studied. Compartment pressures before and after fasciotomy were measured by a standard Whiteside’s device. Various fasciotomies were carried out and associated skeletal and vascular injuries were also noted.Results: The majority of patients were males with average age being 29.33 years. 56.67% patients with upper limb compartment syndrome sustained road traffic injury, 20% were constrictive tight cast, 20% of patients sustained burn and 1 patient was shot by bullet. Of the 30 patients fractures of both ulna and radius (40%) were the most common. Fractures of the humerus, radius, ulna and small bone of metacarpals together account for 36.67% of the affected patients. 3 patients were found to have injury to major vessels. Compartment pressure was measured by Whiteside’s device and fasciotomy resulted in a drastic drop of the pressure from pre-fasciotomy pressure of 44.8±7.9 mmHg to post-fasciotomy pressure of 12.33±3.61 mmHg.Conclusions: The diagnosis of compartment syndrome should be confirmed swiftly and prompt fasciotomy is the treatment of choice. This offers the best chance at decreasing compartment pressure and preventing further damage.

Dichotomy in Fasciotomy: Practice Patterns Among Trauma/Acute Care Surgeons With Performing Fasciotomy With Peripheral Arterial Repair

Introduction Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed. Methods A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution. Results The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome—including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair. Conclusions While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons’ opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.